Making Sushi – The BSG Fellowship to Japan October 2011
Dr Howard Smart
Royal Liverpool University Hospital
The elation of being informed I had been successful in my application for the BSG Fellowship to Japan was tempered by the news of the 11th March earthquake and tsunami that followed. Arriving at Narita Airport on the 2nd October there was little evidence that anything had occurred, except for the collection boxes for victims of the disaster, also prevalent at the shrines and temples visited during our stay.The National Cancer Centre (NCC) in Tokyo is now an independent facility offering treatment and follow-up for all types of cancer. It is situated opposite the Tsukiji Fish Market, a must for any visitor to Tokyo and the best place in town to eat fresh sushi or sashimi. I set the aims of my visit to NCC to improve lesion recognition skills for early upper gastrointestinal (UGI) cancer and to gain experience, by observation and animal model training, of endoscopic submucosal dissection (ESD) in the UGI tract. I concentrated, therefore, on the UGI service provided by the Division of Endoscopy.
UGI work was undertaken primarily by 4 or 5 of the staff doctors, supported by both of the chief residents in turn and as many residents as could fit in the endoscopy room. The hierarchical training system utilised has already been described in Jeff Bateman’s report. Certainly the residents benefited greatly from assisting with the equipment, something I have already introduced onto my training list. The need to bow frequently will be more difficult.
The endoscopy day was split between morning diagnostics and afternoon therapy. Thrown in for good measure I also attended the oesophageal and gastric conferences (all in English) for treatment planning, equivalent to our MDT meeting.
Diagnostic endoscopy consisted of new patients with early UGI cancer (found in screening centres) for assessment of treatment options and follow up of previously resected cases. What did I learn from these? Well, don’t rush, wash everything, take lots of images, dye spray, take more images and finally just do 1 biopsy with paediatric forceps! The Japanese endoscopists will recognise an early cancer macroscopically, classify it with the Paris system (usually 0-llc) and estimate the depth of invasion. They are usually correct.
About 500 UGI resections take place per year, a mixture of ESD and endoscopic mucosal resection (EMR). There were usually 2 or 3 resections scheduled for the afternoon session. A simple cap EMR of an early oesophageal cancer would take 20-30 minutes, whereas a complex ESD of a proximal gastric lesion could take 2 hours or more, utilising propofol sedation. UGI EMR is a procedure I undertake frequently, usually in Barrett’s patients with high-grade dysplasia, using band ligation. At NCC cap EMR was favoured. Almost all oesophageal cancers treated were early squamous lesions. I was more interested in ESD. This was done primarily for early gastric cancer, oesophageal ESD being high risk (10% perforation rate even in expert hands). What are the key points for a successful ESD? Recognise (dye spray) and mark the lesion (APC) using a high definition scope. Use a water-jet enabled scope with a cap for the therapy, utilising CO2 insufflation. Inject and lift the lesion, incise the margins with a needle-knife and subsequently an IT-knife (you guessed it, the NCC is an Olympus unit) until circumferential incision is completed. Deal with bleeding as it arises, the cap and water-jet help here, with coagulation from the IT-knife or hot biopsy forceps. Further injection and horizontal dissection with the IT-knife allows the lesion to be completely removed. Retrieve it and pin it out and hey presto! – human sushi. Finally, buzz all the visible vessels in the raw area to reduce the risk of post ESD bleeding. The patient remains in hospital for about 5 days post gastric ESD with subsequent annual endoscopic follow-up.
We all had the opportunity to perform gastric ESD on the porcine stomach model, both operating and assisting with equipment. Readers will be pleased to know that we were all successful, with no perforation or fatality (amongst the watching Japanese audience)!
Thanks go to Dr Matsuda, our excellent and most hospitable host for a very enjoyable time in NCC. I am personally particularly grateful to Drs Nonaka, Oda, and Yoshinaga for talking me through their procedures. Drs Abe and So were excellent teachers in our attempts to make porcine sushi.